Wound Care in Miami Florida

(or better yet wound healing)

Pretty much everything you need to know about wound care:

Dr. Gitlin has been involved in the treatment of patients with foot and ankle wounds for the past 15 years. He was director of the St. Johns Medical Center wound care and tissue regeneration fellowship as well as medical director of their Hyperbaric and wound care program.  During residency he trained under E. Douglas Newton, MD, in Pittsburgh and Christopher Attinger, MD at Georgetown. 

Since then he has given hundreds of lectures nationally on the subject of wound care surgery, limb salvage, amputation, charcot reconstruction, bone infection among other topics in the field of wound care.

" Wounds always have a reason to be there "

To effectively treat and heal a wound, it is essential to identify its underlying cause. There is a wide range of systemic diseases that can lead to the formation of wounds on an individual's body. However, in the case of lower extremity wounds, most occurrences are attributed to pressure, particularly in many instances of diabetic foot ulcers; others stem from inadequate blood flow or insufficient blood return from the veins to the heart.

We will discuss all of these causes.

Firstly, the most prevalent wound seen in lower extremity practices is the diabetic foot ulcer. The presence of diabetes alone does not directly result in the wound. Rather, it is the peripheral neuropathy that leads to the loss of sensation in the foot, and since the body does not experience pain signals to indicate a problem, the skin gradually deteriorates, resulting in foot ulceration. In wound care, we utilize a grading system known as the Wagner Classification System, illustrated on the left. On the right, you will find another classification system that offers a more comprehensive approach but is less frequently used, known as the University of Texas, included here for your reference.

After we understand the kind of wound we are dealing with, we look for the reasons, in the diabetic there may bone prominences like in cases of charcot foot ( if you want to know more about what CHARCOT is click here ) where the bones break down and form bulges in the skin which rub against the floor and since the patient has no protective sensation the skin ulcerates. 

We also look at the tendons, how are they pulling the patients joints? or are these tendons and muscles not pushing enough are centain muscles overpowering others and creating imbalances and deformities that create the prominent areas that are prone to ulceration?

Many wounds in the ball of the foot can occur simply because the patients have a condition called equinus ( click to learn about EQUNUS ). This is where the achilles tendon is too tight for any reason and the ball of the foot bears most of the weight during walking and causes ulcers in patients without a protective sensation. ( peripheral neuropathy- yes click it if you are interested)

In certain situations, wounds may arise due to insufficient range of motion in a joint, which can result from a previous injury or arthritis, leading to excessive pressure in other areas of the foot and subsequently causing wounds, particularly in patients with some degree of numbness in their feet and legs. Conversely, arterial wounds require distinct attention; they must be managed by a skilled vascular surgeon prior to any treatment being provided. Arterial wounds occur as a result of inadequate blood circulation to the limb.

Venous ulcers, on the other hand, typically manifest on the inner side of the ankle, where blood tends to flow sluggishly, and occur due to improper functioning of the veins, which fail to efficiently transport deoxygenated blood away from the feet back to the heart and lungs. Such venous ulcers are treated through compression and debridement, and should also be evaluated by a vascular surgeon.

We utilize X-rays to assess the condition of the bones, and may request an MRI imaging test if deemed necessary—why is that? X-rays provide insight into the bones, while MRIs enhance our ability to visualize, revealing the internal structure of a bone along with all surrounding soft tissue components such as tendons, ligaments, cartilage, and more. Some practitioners may also order a CT scan or a PET scan, which are additional imaging techniques utilized to gather relevant information.

Usually when we get these tests we are looking for hidden infections. If a wound has been present for a long time the bone beneath it may be infected. This creates a situation where the wound will never completely heal because the infected bone -osteomyelitis ( click to learn about it ).

Once we have all of the information about the wound we can begin treatment, we see most wound patients weekly although when they are doing well we can see them every other week. If you have a wound and are seen once a month find a new doctor.

During those weekly visits we perform wound debridements, we use instruments to clean the wound removing any dead skin and tissue as well as to remove any normal skin bacteria that is colonizing the surface of the wound ( that layer is called the biofilm there is a lot of research on that topic going on now. In some cases we also apply antibiotics directly to the wound.

WHY DEBRIDE A WOUND ?

A wound that did not just happen (acute) is one that becomes neglected by the body, we consider this a chronic wound. There are also cellular changes that occur as well. When we clean the wound we make it bleed again, this tricks the body into thinking that there was an acute injury and helps to restart the healing process. The body then sends blood to the area that contains all the cells necessary for healing an acute injury.

OFFLOADING A WOUND

After the debridement procedure, we either have the patient refrain from bearing weight or put them in a specialized cast known as a total contact cast, or in a custom boot or shoe designed to alleviate pressure on the injured foot. It's important to recall that the majority of common wounds found in the foot and ankle are a result of pressure on bony prominences. Offloading relieves the weight from these areas, promoting their healing. The new, delicate skin cells that constitute the initial layer of healing skin are quite vulnerable to damage from shearing forces, which refer to the side-to-side friction that occurs in the feet while walking.

WHO NEEDS SURGERY ?

If we make a diagnosis that something is resposible for pressing on the skin from the inside we act quickly to remove the bone prominence causing this. In some cases it is to shave down a piece of bone to more extensive bone wedges and realignments. when we do thses surgical deformity correction we often use external fixators ( to learn more about this technique click here ), it is an old technique but one that works extremely well to help hold bones together during healing from the outside just like a scaffold on a building being repaired ,see the case pictures below.

We also use skin graft and flaps-

In fact, we are among the few practices that utilize flaps for wound closure, a technique that is seldom taught today. There is no one else in the tri-state area who is trained in some of these procedures. When discussing surgical wound coverage, there are several options available. The most straightforward is the use of artificial skin substitutes, some of which are derived from cultured baby foreskin, others from shark skin, and some from plant fibers.

Certain products claim to include growth factors essential for healing. Their names include Apligraft, Dermagraft, Oasis, and there are now many more being promoted.

We do not prefer any of these fake skin grafts at all!!!!!!

WHY? "because the best skin is the skin next to it". What I mean is the best skin to close a patients wound is there own skin and when it comes to the bottom of someones foot that has very different skin from other places in the body if you could move skin from right next to it will heal a wound much better- see the cases below to understand this.

How about taking skin from another area in the body and using it to cover the wound?

This procedure is known as a split-thickness skin graft, and we frequently utilize it. A device called a dermatome is employed to carefully remove a thin layer of skin (typically around 0.15 inches—quite thin). The harvested skin is then processed in a machine known as a mesher, which creates uniform perforations in the graft to facilitate wound drainage. After this, these grafts are secured to the wound using staples or stitches. Such skin grafts are suitable only for very shallow wounds that are prepared for the coverage of the top layer of skin. Typically, the harvesting of skin grafts takes place in the operating room; however, we also utilize a device called an epidermal harvest system.

This technology enables us to harvest very thin layers of skin in a pain-free manner through gentle heating in an office setting, allowing us to place these small epidermal grafts directly onto the wound.

WHAT IS A VAC MACHINE?

another way to help get a wound more shallow for possible grafting is the vacuum assisted closure device, a company called KCI made the first one years back and its considered one of the most important skin surgery and wound care inventions in recent history. There are now many other companies that produce and sell a similar product bu nothing beats the original KCI VAC. This machine is a vacuum that attaches to the wound and keeps constant suction on it helping the skin to heal quickly. It stays on the foot and is changes every 3 days.

WHAT ABOUT HYPERBARIC THERAPY ?

We do use hyperbaric treatment on occasion but only in addition to our regular treatment and only in very specific cases. Many wound care centers at hospitals use these on anyone they can only because the hospital gets so much money for that treatment, ill explain later. So do you need hyperbarics or HBO for short- usually not, there is simply not enough research to show that even works. CLICK HERE TO LEARN MORE ABOUT IT

WHAT ABOUT DEEP WOUNDS?

For deeper wounds we have two choices- we can do weekly debridement and get the wound to heal to a shallow level and then skin graft the wound. Or in some cases we can do a rotational flap. These graft are different because we take local skin many time just adjacent to the wound itself and shift it around to cover the wound.

Below is a case of a simple rotational flap, as you can see the skin next to the wound is mobilized to cover the wound, in this case we were able to close the 'donor' site as well.

Below is a more complicated flap for larger wounds in the middle of the foot called a medial plantar artery flap. This is more difficult since when it is made an artery must be kept alive in the flap

We believe that a longer a wound is present the more chance for infection so in many cases of large and deep wounds we now prefer to perform a flap surgery to quickly close the wound. below are some wound flap cases for your interest.

Below is a before and after pic, the wound was cut out completely and stiched closed. An external fixator was applied to the limb ( this is like a scaffold on a building, only in this case we attach it to the bones inside ) This technique of external fixation allows us to stabilize the wound and allow it to heal without movement. The healed picture you see is only 4 weeks after the initial surgery.